It happens over night. You go to bed feeling good and in the morning you still feel fine until your heel hits the floor. It’s back! Stiff, tight, sore with sharp pain starting in your heel and cascading through your foot and even up the lower part of your leg. You did nothing overnight. In fact, you haven’t exercised in over a week. No running. No jumping. Nothing. So, how is it possible you can hurt in the morning? What is this? Why is it happening and what do you do? It has been a year since this started!
Ninety percent of people with plantar fasciitis (pronounced plan-tar-fash-eye-tis) (PF) respond to a variety of non-surgical treatments within the first 6-9 months of the onset. The treatments include anti-inflammatory drugs, massage, stretching, ultrasound, electrical stimulation, iontophoresis, acupuncture, shoe inserts, heel cups and exercise for the foot muscles. If you have PF, the treatment is often a combination of any or all of these things. But for the remaining 10% who still have symptoms after one year and have tried everything, what then? Is surgery the only option?
The plantar fascia is a thick, tough, dense fibrous tissue on the bottom of your foot. Surrounding the muscles and connecting the bones from the ball of the foot to the heel, the plantar fascia acts like a large bowstring supporting the entire bodyweight while maintaining the arch of the foot. It is flexible enough to permit a wide range of foot movement yet strong enough to withstand up to 3-4 times your bodyweight when you run. But, the plantar fascia is not infallible. You can hurt it. Injuring the plantar fascia is usually from, as my good friend Heidi Armstrong says, “pegging the stupidometer”. The mind remembers what the body has long since forgotten. We think we can run faster, jump higher or dunk a basketball when we have no business even thinking about it. Too much force at one time or an accumulation of force over a longer time creates small tears in the bowstring. Inflammation with its calling cards of pain, tenderness and swelling soon follow. After a few weeks, these initial markers of inflammation typically subside and symptoms change. The symptoms now are typically pain first thing in the morning with a gradual improvement and sometimes complete elimination of pain through the day. The symptoms resurface after inactivity such as sitting through a movie or a long commute. The problem now is that the bowstring is weak with small, incompletely healed tears. It can no longer withstand the weight of the body and with each step it reluctantly yields doing its best to tell you it is failing. It needs help.
Most people with PF are told to stretch the heel cord. The thinking goes something like this: if the heel cord is too tight, it causes a further tightening of the plantar fascia thereby ratcheting the bowstring even more. The solution then is to stretch the heel cord. The heel cord stretch is performed in standing. You have probably seen someone doing this before they run. Typically, you face a wall with your feet staggered with one foot further back than the other. You then lean toward the wall moving your lower leg over your foot stretching the back of the leg.
But, I wonder. If the heel cord is too tight, supposedly creating too much tension on the bowstring, wouldn’t stretching the heel cord also stretch the bowstring? Do we want to stand on the injured foot stretching an incompletely healed, weak and failing structure? Is this how injured tissue becomes stronger and more resilient?
The heel cord is not really the problem. The problem is an initial tissue injury of the plantar fascia followed by inadequate repair leading to a weaker plantar fascia such that just being up on the foot is way too much force. What to do?
Injured tissue such as tendon, ligament, cartilage, disc, fascia or muscle, regardless of where it is in the body, responds best to this sequence:
1. Remove or reduce the offending forces for 2-3 days. This is most often some form of weight bearing: jogging, walking, standing or even sitting. It is in this time period when inflammation does its job of kickstarting repair or regeneration.
2. Control swelling by elevating the injured area above the level of the heart for 10 minutes every two hours. Add compression either by wrapping the area with an elastic bandage or using a commercial pressure garment.
3. Move the injured part for 2-3 minutes, exposing it to a light force, several times a day for 10-14 days.
4. Gradually increase both the load and motion over the following 3-4 weeks.
So, if this is all it takes, why don’t people get better? Mostly because they do not follow the rules. The mind gets in the way. We live in denial of the truth. We are hurt. Slow down. Ease up. Give your body a chance. But, many people choose to continue hurting themselves. We run. We have to run. We need to run. Why? There are many reasons why a person would choose to run on a painful foot but nearly all of them are rooted in the unconscious part of the mind. Running, even though it hurts, is less painful than what not running represents. Maybe it is the idea of growing old or being vulnerable. Maybe we run to control our weight so we can eat what we want when we want to or keep the stress monster at bay. If any of this resonates with you, ask yourself why? Why am I running? What am I running from or to? Your choices are influenced by the unconscious. You cannot control what you do not know. Make the unconscious motives conscious by asking yourself, “Why am I doing this?”
My approach with clients who have PF includes the four steps above. But more specifically I do these things:
1. Use a heel wedge in the shoe. A heel wedge tilts the foot down and reduces the tensile stress on the fascia (remember, step one is to reduce or eliminate the offending forces).
2. Get off your feet for 2-3 minutes every two hours elevating the foot above your heart and move your feet and toes up and down (step number two above).
3. If walking hurts, I use an unloading machine (Newton Speed Trainer) to discover the pain free threshold for walking or running. The Newton essentially makes you weigh less. So, you can walk or run without the pain, fear of injury and heal yourself at the same time. I then prescribe a crutch to support some of the body weight (I can hear screams of resistance “A crutch! You’ve got to be kidding! I don’t need no stinking crutch!”).
4. From week to week, the weight bearing loads will be increased. I test the weightbearing load each week. A cane replaces the crutch. I use a thinner heel wedge.
5. Once walking with their entire weight on the foot no longer hurts, I prescribe a walking and jogging routine which starts with a 15 second fast walk followed by a 45 second slow walk. This cycle repeats for a total of 20 minutes. If the client’s objective is to run, they run in the arms of the Newton until they can run using their entire body weight.
But, where is the stretching? After all, stretching is the gold standard in treatment of PF. Here is why I do not ask clients to stretch the heel cord or the fascia. They can’t. The bowstring is too strong. To give you an idea of how strong, the average amount of force required to stretch it one inch is 950 lbs.! (Gefen A. The in vivo elastic properties of the plantar fascia during the contact phase of walking. Foot Ankle Int. 2003 Mar; 24(3):238-44). Kind of like trying to stretch the bumper of a car. But, what I would consider doing, if you feel strongly about stretching is this:
1. Take off your shoes and socks, then sit down on a chair and cross your legs with the painful foot on top of your other knee.
2. Grasp your toes and pull your foot and toes backward until you feel a light stretch in the bottom of your foot. Hold the stretch for 10 seconds then release the stretch.
3. Repeat this 10 times and perform it at least three sessions through your day.
So, you may be wondering why I would suggest a stretch when I just said I do not use stretching. Very good, grasshopper.
Every now and then a scientific study appears which supports something I do. It always feels good to be validated. The study was published this year and compared two types of stretching for people with chronic PF. One stretch was performed while standing (the heel cord stretch) and the other while sitting (the stretch listed above). The group who stretched while sitting responded much better than the group who did the heel cord stretch. But, did they really stretch the fascia? No way. The sitting stretch interrupts the force due to gravity at least three times more than the standing stretch. The key to success then is interrupting the excessive force. How about them apples!
My suggestion is to follow the four rules of tissue healing. An injury is the best time to discover your weaknesses both physically and psychologically. Give your body a chance. Help it heal. Study your resistance to simple instructions and remove the barriers to wellness.
And one more thing. The absence of pain does not equate to wellness. Now that you feel better, it’s time to invest in your body. It just gave you the chance.
Make today count.
Reference: DiGiovanni BF, Nawoczenski DA, Lintal ME, Moore EA, Murray JC, Wilding GE, Baumhauer JF. Tissue-specific plantar fascia stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study.
J Bone Joint Surg Am. 2003 July; 85-A(7):1270-7.